Latino OCD Genetics Study- Sign Up!
A compensated study to identify genetic factors contributing to the development of OCD. You will either provide a spit sample in person or send it to us via mail in a kit we provide. Applicants must: Have at least 1 grandparent who identifies as Latino/Hispanic Be 7-89 years old Have experienced symptoms of OCD now or in the past. No official OCD diagnosis is required Learn More: LATINO OCD Genetics Study Flyer (PDF)
Reflections on Our OCD Awareness Event
What are October OCD Awareness events all about? OCD Awareness Week was launched by the International OCD Foundation (IOCDF) to serve as an annual occasion when “community groups, service organizations, and clinics across the US and around the world celebrate throughout the week with events such as educational lecture series, OCD-inspired art exhibits, grassroots fundraisers, and more.” In addition to events hosted by the IOCDF (www.iocdf.org), affiliate organizations around the world offer a range of programs and activities in their local communities. The San Francisco Bay Area’s affiliate, OCD SF Bay Area (www.ocdbayarea.org), has grown during the last several years and now sponsors numerous events around the SF Bay Area. Although OCD Awareness Week is the second week of October, the Bay Area now offers too many events to be limited to one week. As one of the members of the Board of Directors of OCD SF Bay Area, I enjoy how we now affectionately refer to October as OCD Awareness Month in the Bay Area! SFBACCT’s participation in OCD Awareness events The SFBACCT has been proud to play a significant role in hosting and participating in OCD Awareness Week events for the past four years. Sponsored by the OCD SF Bay Area affiliate, this year we teamed up with Rogers Behavioral Health and TMS Health Solutions to host two-panel discussions and Q & A’s on various aspects of OCD. One panel focused on treatment for adults; the other focused on treatment for children and adolescents. It was such a pleasure to work closely with some of our Bay Area colleagues. Joan Davidson served on the adult panel along with Jennifer Park from Rogers Behavioral Health, Ryan Vidrine from TMS Health Solutions, and Heidi Hartston, an individual practitioner. Daniela Owen and Jonathan Barkin served on the child and adolescent panel with Margo Thienemann from Stanford Children’s Health. Both panels included presentations and discussions by two young adults who have experienced treatment first-hand. Our OCD Awareness event took place on Sunday, October 6th, 2019, at the UC Berkeley Alumni House on the UC Berkeley campus. This is the second OCD Awareness event that we’ve hosted at this venue, and we enjoy the convenient location, comfortable presentation space, and friendly staff who help with all aspects of preparation. We were pleased to have had about 60 attendees. We covered numerous topics and enjoyed lively discussions. Adult panel topics included an overview of OCD and ERP, appropriate levels of care, roles of loved ones during treatment, psychopharmacology, and Transcranial Magnetic Stimulation (TMS) as a treatment option. Child and adolescent presenters discussed differences between adult and child presentations of OCD, youth expressions of anger in OCD, family accommodation, the arc of treatment and building acceptance and compassion when helping children and teens, research updates on PANS and autoimmune connections with childhood OCD, and current research on medications to treat OCD. Looking toward the future Our Center is excited to continue hosting October OCD Awareness events in the coming years, and we look forward to continuing our collaboration with colleagues from around the Bay Area. These events are for general audiences, people with OCD, family members, and therapists. We hope to see you next year! If you’re interested in joining the SF Bay Area Affiliate of the IOCDF and receiving electronic newsletters with updates about all local OCD Awareness events as well as information about events, resources, and support groups throughout the year, please go to www.ocdbayarea.org. We’ll keep you updated about our participation in events in our newsletter, which you can join at www.sfbacct.com.
Why it’s worth it: Committing to ERP for OCD during treatment and beyond!
Many people feel hopeful after reading about OCD and learning that treatment may help them. At the same time, as they learn about what exposure and response prevention (ERP) entails, they often feel caught between a rock and a hard place. As awful as OCD is, therapy that involves facing your worst fears may also sound awful. Deciding to start treatment takes courage. Practicing ERP during treatment takes commitment. Choosing to embrace ERP as a life-long goal takes determination. Knowing why it’s worth it can make a world of difference. ERP, the gold standard of treatment for OCD, involves facing obsessions and situations that trigger them without using compulsions. By changing your responses to obsessions, you break the OCD cycle. The concept is rather straightforward. There are many resources available to learn about ERP. Skilled therapists can guide you through the process. Yet the thought of facing obsessions head-on and not using compulsions can seem terrifying and beyond reach. If you’re beginning treatment, you may question if it will work for you or if you’ll be able to do it. Of course, no one can provide you with certainty (an underlying theme in OCD!), but you can work with a therapist to consider the potential advantages and disadvantages of committing to treatment. What do you have to gain? What do you stand to gain or lose if you don’t try? Taking time to discuss why ERP is worth it not only helps clients get started, but it also helps when the going gets tough during and after treatment. Jeff Bell, news anchor, author, and mental health advocate, writes and speaks about the importance of finding your “greater good” goals when facing the challenges of OCD. Exercises like those used in Acceptance and Commitment Therapy (ACT) help clients identify what they most value across various life domains, which helps them commit to taking actions (like ERP!) to live a life that that is consistent with their values. Answers to questions like, “How does OCD interfere with living true to my values?” can help clients identify their “greater good” and pave the way toward committing to treatment. Challenge: Handling “choice points” every day. It’s one thing to have the “big picture” perspective about what you value more than giving into the OCD cycle, but remembering those values and choosing to act in accordance with them can be extremely challenging in the moment when faced with an OCD trigger. Those “choice point” moments are where the action is. When faced with an obsession, remind yourself exactly why on earth you’re choosing to lean in toward your fears and not use compulsions. I ask my clients to do this all the time. We choose obsessions and situations to face, behavioral responses to change, uncertainties to accept and embrace, and “greater good” reasons to do it. The more you practice “calling out” your greater good reasons for facing obsessions without using compulsions, the more likely you’ll remember them and call upon them when faced with unexpected challenges. Keep a “Positive Log” of victories, meaning decisions to take steps in the service of greater good values when facing OCD triggers. These victories can be small steps. Review your log regularly and remind yourself about the progress you’re making. Challenge: Remembering the treatment goal. At some point during treatment, you might feel discouraged if new obsessions pop up or if old obsessions resurface. You may feel like you’re failing. The content of obsessions can morph and change over time. That’s the nature of OCD. What you’re changing is how you respond to obsessions, whenever they occur and whatever form they take. What you’re challenging is how you deal with themes such as trouble tolerating uncertainty or things not feeling “just right/just so.” The goal is not to rid yourself of obsessions or anxiety forever; the goal is to change your responses. Writing down your treatment goals (i.e., changing how you respond to obsessions and the anxiety they provoke) when monitoring your progress helps you stay on track, even when new or old obsessions may catch you off-guard. Challenge: Feeling like it never ends! No matter how much great work you do in treatment, it can feel disheartening when you think about how this work never truly ends. You may want to forget about OCD for a while. You may feel like you deserve a break! Unfortunately, if you stop using the ERP tools you’ve learned, you’re likely to backslide. Remembering how you want to live your life and why this ongoing work is worth it can be especially important when you finish treatment. Keep reminders of your values and goals visible and easy to access. Continue reviewing and updating your Positive Log. Challenges will arise, and some of them may be difficult, but remember, you’ll be armed with new skills to respond to obsessions and you’ll become quite adept at using them. Seek support! You don’t need to feel alone after treatment ends. Consider meeting with your therapist for follow-up sessions. Participating in or starting a local OCD support group, joining an on-line support group, attending talks and local workshops about OCD, and of course, attending the IOCDF conferences are all great ways to find support, stay motivated to challenge OCD, and remember why it’s worth it.
Preventing Relapse in the Treatment of Obsessive-Compulsive Disorder: Life-Style Exposures
Obsessive-compulsive disorder (OCD) is a chronic condition and therefore even following an effective treatment, your client always and will forever face the possibility of relapse. Assisting the client to manage the risk of relapse is an essential part of treatment for the condition. As you taper sessions with the client, use the times between sessions to assist the client to practice the relapse prevention plan you and the client developed. An effective relapse prevention plan includes several features, such as practicing and reinforcing life-style exposures. Life-style exposures. An effective relapse prevention plan includes opportunities for the client to practice responding adaptively when in the course of everyday life situations trigger his OCD symptoms. The manner with which a client responds to these unplanned exposures can tell you much about whether the client has truly adopted an effective recovery attitude. Brainstorm with the client the life-style exposures he is likely to experience before he next meets with you. Ask him to write these on a monitoring form and add space for him to note other life-style exposures that arose but that you did not include on the form. Develop with the client an appropriate response to a life-style exposure – approach and remain without engaging in any attempt to decrease his anxiety or neutralize the obsession. Develop imaginal exposures to these life-style events and practice in session. In particular, check that the client is responding appropriately to the obsessions and distress triggered through the imaginal exposure. Include on the form space for the client to list new obsessions, compulsions, or triggers and of course, when you meet with him, praise the client for successfully completing life-style exposures.
Nuts and Bolts of Imaginal Exposure
Imaginal exposure involves the client imagining the feared object or situation to evoke fear and anxiety. Research has demonstrated that direct in vivo exposure to feared objects or situations is more effective than imaginal exposure to the same circumstance. However, the combination of both exposure strategies has produced excellent outcomes and, at times, imaginal exposure is the only exposure strategy therapists can use to treat a specific fear, such as a client who fears dying from a toxic substance at some unknown and distant date in the future. At other times, therapists can use imaginal exposure when in vivo exposure is not practical, such as a client who fears that the plane he is on will crash, but he cannot afford to fly frequently enough to treat the fear through in vivo exposure. At other times, imaginal exposures are effective “warm-up” exposures prior to the client participating in in vivo exposures. The first step in implementing imaginal exposure is to develop a hierarchy of fear-evoking scenes arranged from least anxiety evoking to most anxiety evoking. The next step is to construct the scenes themselves. Imaginal scenes are vivid movie-like images that the therapist guides the client through to evoke anxiety and discomfort. The scenes include descriptions of sensory elements (sound, sound, smell, taste, touch) as well as descriptions of the setting and the client’s actions. The final step is to implement the imaginal exposure. The therapist instructs the client to sit in a comfortable chair, close his eyes and to “be in the movie” rather than observing it as if he were in the audience watching the movie. The therapist then describes the elements of the scene while asking the client to describe what he sees, hears, touches, smells, feels emotionally, feels physiologically, and thinks. The scene is recorded on an audiotape for the client to listen as homework. The recorded scenes can be brief. Often 2-5 minutes is good. The client listens to the recording three to five times and then rates his anxiety (0 to 10, where 10 is extreme). The client then returns immediately to the recording and repeats this process. In addition to these basic guidelines, I recommend therapists attend to the following when conducting imaginal exposures with clients. Include response prevention in the imaginal scene. Response prevention is an essential strategy in the effective treatment of any anxiety disorder whereby the therapist blocks the avoidance strategy, either actions such as a compulsion, or thought actions such as mental reassurance, analysis, or internal checking. For example, the therapist treating a client with germ obsessions who washes his hands after touching a doorknob would instruct the client to touch a doorknob but not wash his hands. Similarly, a therapist might instruct a client with generalized anxiety disorder who fears something terrible will happen to her husband during his commute, to not call him as she usually does when he arrives at work. It is essential that therapists block mental safety behaviors during imaginal exposures in order that clients experience a full and effective exposure. For this reason, I recommend therapists include response prevention in imaginal exposure scripts. For example, a client with contamination obsessions that cause him to feel dirty and uncomfortable when he touches most anything and who then washes his hands for 30-40 minutes, would listen to an imaginal audiotape that describes him touching a counter and feel the contamination coating his hands, climbing up his arms and spreading across his face. The therapist includes the response prevention piece in the script by adding, “You go to the bathroom and wash your hands, like you usually do. But this time, the feeling of contamination does not decrease but continues to grow and grow. You desperately continue to wash your hands, but again and again you leave the bathroom with the feeling of contamination growing and growing.” Block self-reassurance. Therapists are likely familiar with anxious clients who repeatedly seek reassurance from their partners, family members, physicians, and therapists. They ask, “Do you think it’s okay if I don’t wash my hands right now?” or they check with them whether the feared disaster has occurred, “I heard that feeling flush and nauseous is one of the first signs of food poisoning. My face doesn’t look flush does it?” Similarly, clients engaged in imaginal exposure can fall into a pattern of reassuring themselves as they listen to the audiotaped scene. They might think, “I know this isn’t really happening. I’m just listening to a tape.” Or, “My therapist must not think this would ever really happen or he wouldn’t have asked me to imagine this scary scene.” I recommend therapists check with clients whether they are doing this, particularly if the client tends to over-analyze events or if they have sought reassurance aloud from the therapist. When clients admit to reassuring themselves, review with them the importance of listening to the scene as if it is really happening and to counter these reassuring thoughts with phrases such as, “Well, I can’t be sure that I won’t get sick and die. My therapist can’t be absolutely certain, now can he?” If the problem continues, again remind the client that if the exposure scene is too anxiety-evoking for him to hold fully in their awareness without reassuring themselves, they can drop down in the hierarchy and try a less fear-evoking scene or modify this one so that it is more manageable. Block cognitive avoidance. At times during imaginal exposure, clients will distract themselves to a neutral image to avoid fully interacting with the fear-evoking scene. I recommend therapists ask their clients whether they are doing this, particularly if they observe that the client has reported little or no anxiety as they listen to the imaginal exposure recording. When therapists encounter this problem, explain to clients the importance of making every imaginal exposure count and remind them that if this exposure is too anxiety-evoking for them to hold fully in their awareness they can drop down in the hierarchy and
Uncertainty
Uncertainty can feel uncomfortable, very uncomfortable. It can feel frightening and even dangerous. We can’t avoid it, although we often try. Yet, when we learn to work with it and even embrace it, (yes, embrace it!), we can be more open, curious, and free from the struggle of trying to control it. Uncertainty is a word that’s showing up a lot these days in psychological literature and in social media. How do we handle uncertainties in life? How do our patients view uncertainty and what do they do when faced with it? Uncertainty is something we must contend with as human beings. We’re pretty certain that we will die. Most of us don’t know when, where, or how. Everything between now and then is chock -full of uncertainty. It’s how we live with uncertainty that makes a world of difference. When I was younger, life was full of uncertainty yet it seemed like one big exciting adventure. The older I get, some things have become more certain, and that’s what frightens me! But everyone has their own relationship with uncertainty. People prone to worry spend much of their life trying to control it. People with Obsessive Compulsive Disorder (OCD) respond to certain triggers of uncertainty as life-threatening. Trying to get out from under uncertainty and find reassurance may seem to make good sense but usually results in more problems than benefits. Uncertainty lies at the heart of OCD, and it’s what our patients accept and embrace as they face their fears without using compulsions.* Recently, I’ve been researching and writing about transdiagnostic mechanisms underlying a range of psychological problems, and intolerance of uncertainty is a theme that cuts across many of them.* Clinicians are benefitting from decades of research about the role that intolerance of uncertainty plays in psychological disorders. There’s even a cognitive-behavioral protocol (CBT-IU) for Generalized Anxiety Disorder (GAD) that targets intolerance of uncertainty and related psychological mechanisms.* Coping with uncertainty is not just a problem for people with anxiety disorders. It can be a struggle for many people during the course of everyday life, which is why I’m delighted to work with Jeff Bell and Shala Nicely as part of their organization, Beyond the Doubt, offering workshops to help everyone consider embracing uncertainty in the service of pursuing their greater good goals in life. Jeff’s book, When in Doubt, Make Belief , includes insights from a range of inspirational people about their perspectives on uncertainty. By embracing uncertainty, we can help ourselves and others find increasingly creative and meaningful ways to live the lives we aspire to live. Bell, J. (2009).When in doubt, Make belief: An OCD-inspired approach to living with uncertainty. Novato, CA: New World Library. Davidson, J. (2014). Daring to challenge OCD: Overcome your fear of treatment & take control of your life using exposure and response prevention. Oakland, CA: New Harbinger. Frank, R.I. & Davidson, J. (2014). The transdiagnostic approach to case formulation and treatment planning: Practical guidance for clinical decision making. Oakland, CA: New Harbinger. Robichaud, M. (2013). Cognitive behavior therapy targeting intolerance of uncertainty: Application to a clinical case of generalized anxiety disorder. Cognitive and Behavioral Practice 20, 251-263.